A two-phase project aimed at preventing worsening disability in nursing home residents with cognitive impairment. The overall purpose of the project is to increase an understanding of how disability progresses and to determine whether risk factors for worsening disability can be modified by existing nursing home staff, slowing the rate of functional decline in cognitively impaired residents. Specific aims are to: (1) analyze trajectories of decline in functional status in long-stay nursing home residents with cognitive impairment to determine whether modifiable clinical and care factors influence decline; (2) identify subgroups of nursing home residents with cognitive impairment who have atypical patterns of decline, characterized by either frequent fluctuations in ADL status or steeper than average slope of decline, and 3) examine the feasibility and preliminary effects of an intervention designed to reduce risk factors for disability progressing in cognitively impaired long-stay nursing home residents. In the first phase, a secondary analysis of functional decline in long-stay nursing home residents with cognitive impairment will be conducted, using multi-year data from the HCFA-sponsored Nursing Home Case Mix and Quality Demonstration Project. Hypothesis concerning the influences of co-existing chronic diseases and cognitive impairment, sensory and neuromuscular impairments, and limitations in function in changes in self-care ability will be tested, along with hypotheses about care factors that may influence change. Results from the analyses will be used to identify subgroups of residents at high risk of decline and to isolate modifiable risk factors for decline. In the second phase, we will conduct a pilot randomized trial to test the feasibility and efficacy of a multiple risk factor reduction intervention to present worsening ADL function in nursing home residents by comparing outcomes to usual care. In this intervention, existing nursing home staff will be taught new methods for risk factor screening, using a combination of nursing home Minimum Data Set items and other performance-based assessments of residents' transfer skills and walking. Staff will also be taught how to implement risk reduction protocols, including exercise built into daily routines to compensate for or mediate performance deficits.